Medication Administration Error Due to Failure to Update and Remove Discontinued Medication Blister Pack
Penalty
Summary
A deficiency occurred when a resident with Parkinson's disease, dementia, diabetes, and a recent hip fracture was administered an incorrect dosage of Carbidopa-Levodopa. Upon admission, the resident had a hospital discharge order for Carbidopa-Levodopa 25-100mg, five tablets daily, but the order did not specify administration times. Facility staff entered this order into the electronic medical record (EMR) and began administering five tablets at once, as indicated by the hospital discharge summary and the resident's home medication bottle. The medication was administered from both the resident's personal supply and pharmacy blister packs, which were labeled for five tablets per dose. Multiple staff, including medication aides and nurses, followed this order and administered the medication as written, without clarifying the timing or questioning the appropriateness of the dose frequency. Subsequently, the nurse practitioner reviewed the medication regimen and changed the order to split the total daily dose into multiple administrations throughout the day. New blister packs were ordered to reflect the updated dosing schedule, and a change in direction sticker was placed on the old blister pack. However, the discontinued blister pack with the previous instructions remained on the medication cart. On the day of the incident, a medication aide administered five tablets at once from the old blister pack, not noticing the change in direction sticker or verifying the new order on the MAR. This resulted in the resident receiving a higher dose than prescribed under the new order. The error was discovered later in the day when another medication aide noticed a discrepancy between the MAR and the blister pack, and the resident exhibited altered mental status and lethargy. Interviews with staff revealed a lack of critical thinking and failure to follow the five rights of medication administration, including verifying that the medication label matched the current physician order and MAR. The medication aide who administered the incorrect dose stated she followed the blister pack instructions and did not see the change in direction sticker. Other staff members indicated that the discontinued blister pack should have been removed from the cart when the order was changed. The resident was subsequently transferred to the hospital for evaluation after the medication error was identified and a change in condition was observed.